1. “REHABBING” AMPUTEES: Caught between AROC and a hard place?
Craig Evans
Physiotherapist
Rankin Park Limb Centre

3. Is anyone else finding it harder?
Are patients :
More unwell?
More comorbities?
Older?
Less motivated?
Lower socioeconomic groups?
More challenging accommodation?
MORE COMPLEX?

4. DATA?…. AROC!

5. Data Collection
The AROC data collection compares our Data with similar units and national data
The CORE report should be considered in conjunction with relevant Impairment Specific reports and the Target Outcomes report for your facility
The AROC database is only as good as the quality and completeness of the data that are submitted to it.
There are 3 reports the core report etc

6. Results summarised Admission: RPC has increased complexity of patients
Increased comorbidities
Increased patients with carer and support
Decreased admission FIM’s
Inpatient:
Increased LOS ( Due to external service issues )
Decreased complications ( RPC good nursing care )
Discharge:
Lower FIM scores
Increased FIM change
Increased services at home but increased discharge to home
Overall as compared to our national benchmarks: We have a lower admission and discharge FIM score and longer LOS than the benchmarks but we are getting more of our patients home with increased services and carers other than Residential placement.

7. Improving data collection over time…

8. Episodes of care at RPC

9. FIM change over 10 + years

10. Average Age change over the years

11. More FIM data…

12. Overall admissions

13. Comorbidities…

14. So why are our patients “less rehabbable”?
Cognition; Motivation; potential; support

15. So why are our patients “less rehabbable”?
More complex patients - definitely
Better pre-amputation interventions
Reduced “Life reserve”
Economics: Public vs private
Private insurance – socioeconomics issue reduced
“Rural” – lower SE groups
Motivation?

16. Better Interventions & “Life Reserve”
Life span
Birth to death
Living with comorbidity
E.G diabetes. Requiring medical management of a condition.
“Life Reserve”
The time frame from hospitalization due to comorbidity including rehab til mortality

17. Better Interventions & “Life Reserve”
Life span
Birth to death
Living with comorbidity
Improvements in interventions increase the time frame of relative wellness prior to requirement for rehab
“Life Reserve”
Less life reserve due to age and “managed” comorbidities. By the time they reach here their potential for rehab is reduced.

18. What makes a good rehab candidate?
Cognition; Motivation; potential; support

19. What makes a good rehab candidate?
Motivation
Potential – physical, cognitive
Support
“House, nous and spouse”

20. What then should be our expectations?
How good should our patients get?
Walking
ADLs
Home
Predictors of outcome?

21. Predictors of function: Taylor et al 2005
Pre-op factors ?= post-op function / mortality
With view to performing palliative AKA vs functional BKA
>= 70 y.o – 3x or more chance of death, non-ambulatory, non-prosthetic user, functionally dependent within 1 year
Other pre op predictive factors – nonambulatory / transfers only; dementia; coronary artery disease; ESRD

22. Predictors of function : Schoppen et al (2003)
Best predictors:
Age at amputation important for general functioning.
Standing balance on the unaffected limb at 2 weeks post amputation – significant predictor of all functional outcome parameters
Memory +/- mood/cognitive ability
Comorbidity (DM and other but not cardiopulmonary disease)
No social predictors were significant

23. Predictors of function: Gailey et al, 2002
AMPPRO / AMPnoPRO (Gailey et al, 2002) – more a functional test than a predictor.

24. Predictors of function : Whyte And Carroll (2004)
Patients with phantom pain (questionnaire, 62% response rate, 315 subjects)
Catastrophizing can account for 11% overall level of disability

25. Predictors of prosthetic non-use: Roffman et al (2014)

26. What does all this mean for us?
Patients are getting more complex, not necessarily older.
There are predictors of function to use as a guide. (Need to be more objective? ABF)
“Rehabbing” the pre-amputees – vascular rehab?

27. References:
AROC Reports --- John Hunter Hospital (Rankin Park Unit)
Gailey RS, Roach KE, Applegate EB, Cho B, Cunniffe B, Licht S, Maguire M, Nash MS. (2002). “The Amputee Mobility Predictor: an instrument to assess determinants of the lower-limb amputee ability to ambulate.” Arch Phys Med Rehabil 2002;83:
Schoppen T, Boonstra A, Groothoff JW, de Vries J, Go¨eken LN, Eisma WH. (2003) “Physical, mental, and social predictors of functional outcome in unilateral lower-limb amputees.” Arch Phys Med Rehabil 2003;84:
Whyte and Carroll (2004). “The relationship between catastrophizing and disability in amputees experiencing phantom pain.” Disability & Rehabilitation 26(11):
Taylor SM et al (2005). “Pre-operative clinical factors predict post-operative functional outcomes after major lower limb amputation: An analysis of 553 consecutive patients” Journal of Vascular Surgery 2005; 42:
Roffman CE, Buchanan J, Allison GT (2014) “Predictors of non-use of prostheses by people with lower limb amputation after discharge from rehabilitation: development and validation of clinical prediction rules.” Journal of Physiotherapy 60: 224–231

28. Acknowledgements
CNC/CNS at RPC – Merridie Rees, Helen Baines and Judith Dunne
Tara and Jackie from AROC